Visual Function, Sports and Recreational Activities Scale
Function, Sports and Recreational Activities : 0.0%
Visual Participation in Physical Activities Scale
Participation in Physical Activities : 0.0%
Visual Quality of Life Scale
Quality of Life : 0.0%
Instructions: This questionnaire asks for your view about your hip and/or groin problem. The questions should be answered considering your hip and/or groin function during the past week. This information will help us keep track of how you feel, and how well you are able to do your usual activities.
Answer every question by checking the appropriate box. Check only one box for each question. If a question does not pertain to you or you have not experienced it in the past week please make your “best guess” as to which response would be the most accurate.
Symptoms These questions should be answered considering your hip and/or groin symptoms and difficulties during the past week
1. Do you feel discomfort in your hip and/or groin?
2. Do you hear clicking or any other type of noise from your hip and/or groin?
3. Do you have difficulties stretching your legs far out to the side?
4. Do you have difficulties taking full strides when you walk?
5. Do you experience sudden twinging/stabbing sensations in your hip and/or groin?
Stiffness The following questions concern the amount of stiffness you have experienced during the past week in your hip and/or groin. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip and/or groin
6. How severe is your hip and/or groind stiffness after first awakening in the morning?
7. How severe is you hip and/or groin siffness after sitting, lying or resting later in the day?
Pain
8. How often is your hip and/ore groin painful?
9. How often do you have pain in areas other than your hip and/or groin that you think may be related to your hip and/ore groin problem?
The following questions concern the amount of pain you have experienced during the past week in your hip and/or groin. What amount of hip and/or groin pain have you experienced during the following activities?
10. Straigtening your hip fully
11. Bending your hip fully
12. Walking up or down stairs
13. At night while in bed (pain that disturbs your sleep)
14. Sitting or lying
15. Standing upright
16. Walking on a hard surface (asphalt, concrete, etc.)
17. Walking on an uneven surface
Physical function - Daily Living The following questions concern your physical function. For each of the following activities please indicate the degree of difficulty you have experienced in the past
18. Walking up stairs
19. Bending down, eg. to pick something up from the floor
20. Getting in/out of car
21. Lying in bed (truning over or maintaining the same hip position for a long time)
22. Heavy domestic duties (srubbing floors, vacuuming, moving heavy boxes etc)
23. Squatting
Function - Sports and Recreational Activities The following questions concern your physical function when participating in higher-level activities. Answer every question by ticking the appropriate box. If a question does not pertain to you or you have not experienced it in the past week please make your “best guess” as to which response would be the most accurate. The questions should be answered considering what degree of difficulty you have experienced during the following activities in the past week due to problems with your hip and/or groin.
24. Running
25. Twisting/pivoting on a weight bearing leg
26. Walking on an uneven surface
27. Running as fast as you can
28. Bringing the leg forcefully forward and/or out to the side, such as kicking, skating etc.
29. Sudden explosive movements that involve quick footwork such as accelerations, decelareations, change of directions etc.
30. Situations where the leg is stretced into an outer position (such as when the leg is placed as far away from the body as possible)
31. Are you able to participate in your preferred physical activities for as long as you would like?
Participation in physical activities The following questions are about your ability to participate in your preferred physical activities. Physical activities include sporting activities as well as all other forms of activity where you become slightly out of breath. When you answer these questions consider to what degree your ability to participate in physical activities during the past week has been affected by your hip and/or groin problem.
32. Are able to particpate in your preferred physical activities at your normal performance level?
33. How often are you aware of your hip and/or groin problem
Quality of Life
34. Have you modified you life style to aviod activities potentially damaging to your hip and/or groin?
35. In general, how much difficulty do you have with your hip and/or groin?
36. Does your hip and/or groin problem affect your mood in a negative way?
37. Do you feel restricted due to your hip and/or groin problem?
PRINT
EXPORT TO CSV
RESET
Positive
Negative
Web Design Copyright 2020-2021 Orthopaedic Manipulation